Acculturative Stress and Depression among Latinos/As: Investigating the Role of Neighborhood Context

Transcription

1 University of South Carolina Scholar Commons Theses and Dissertations 2017 Acculturative Stress and Depression among Latinos/As: Investigating the Role of Neighborhood Context Rebeca Castellanos University of South Carolina Follow this and additional works at: Part of the Clinical Psychology Commons, and the Community Psychology Commons Recommended Citation Castellanos, R.(2017). Acculturative Stress and Depression among Latinos/As: Investigating the Role of Neighborhood Context. (Master's thesis). Retrieved from This Open Access Thesis is brought to you for free and open access by Scholar Commons. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact

2 ACCULTURATIVE STRESS AND DEPRESSION AMONG LATINOS/AS: INVESTIGATING THE ROLE OF NEIGHBORHOOD CONTEXT by Rebeca Castellanos Bachelor of Psychology Universidad Centroamericana José Simeón Cañas, 2013 Submitted in Partial Fulfillment of the Requirements For the Degree of Master of Arts in Clinical-Community Psychology College of Arts and Sciences University of South Carolina 2017 Accepted by: Kate Flory, Director of Thesis Myriam Torres, Reader Cheryl L. Addy, Vice Provost and Dean of the Graduate School

3 Copyright by Rebeca Castellanos, 2017 All Rights Reserved. ii

4 DEDICATION To my mom, my dad, and my siblings for your unwavering support, and for always encouraging me to pursue my goals. Thank you for serving as role models, for your kind and loving words and gestures, and for always telling me I can do whatever I put my mind to. None of this would have been possible without you. Para mi mamá, mi papá y mis hermanos por su apoyo incondicional y por siempre animarme a seguir mis metas. Gracias por ser mis modelos a seguir, por sus palabras y gestos llenos de amor, y por siempre decirme que puedo hacer lo que me propongo. Nada de esto habría sido posible sin ustedes. iii

5 ACKNOWLEDGEMENTS This project would not have been possible without the support of my advisor, Dr. Kate Flory. Thank you for your unwavering confidence, I m especially grateful for the trust you put in me to finish this project, for your constant words of encouragement, and for all the feedback you provided. I d also like to thank Dr. Myriam Torres for serving as my second committee member. Your willingness, input and support was strategic in completing this project. I d also like to thank my kind and amazing friends. Kinjal, Andrew, and Michelle. Thanks for being my writing partners, thanks for spending hours and hours sitting next to me, making writing a little more enjoyable. Esmeralda, Monica and Camila, thank you for being my international cheerleaders, your confidence in all my endeavors keeps me going. iv

6 ABSTRACT Latinos/as are the fastest growing demographic in the United States (U.S. Census Bureau, 2015). As they encounter U.S. society, Latino/as may experience acculturative stress (Berry, 1997). Empirical evidence suggests that Latinos/as in the U.S. report high rates of depression symptoms (Wassertheil-Smoller et al 2014). Acculturative stress has been strongly associated with depression (Driscoll & Torres, 2013) and research suggests that Latino/as may experience acculturative stress differently depending on their generational status (i.e., how recently they or their parents immigrated to the U.S). There is evidence to suggest that contextual factors such as neighborhood context may influence both acculturative stress processes and mental health outcomes (Vega et al, 2011). The current study examined how two aspects of neighborhood context -neighborhood safety and social cohesion- interacted with acculturative stress and depression among first generation Latino/a immigrants. We utilized secondary data from the National Latino Asian Study (NLAAS). It was found that acculturative stress and neighborhood safety significantly predicted depression symptoms. In addition to assessing the relation between acculturative stress and depressive symptoms with the whole sample, we sought to determine whether acculturative stress was associated with depression symptom severity among a subset of the sample that endorsed at least one symptom of depression. We found that the association did not hold with this subset of the sample. Differences in findings suggest that first generation Latino/a immigrants with high levels of acculturative stress may be at-risk of experiencing depression symptoms. However, once v

7 depression symptoms are reported, acculturative stress may not be as influential in determining depression severity (Hovey, 2000). Moreover, the interaction of acculturative stress, neighborhood safety, and social cohesion did not predict depression symptoms. This may have occurred because other factors that were controlled for, such as SES, race, gender and citizenship status, explained more variance in the model than acculturative stress, neighborhood safety, and social cohesion. Finally, we present implications for research and practice that may be drawn from this study. vi

8 TABLE OF CONTENTS DEDICATION... iii ACKNOWLEDGEMENTS... iv ABSTRACT...v LIST OF TABLES... ix CHAPTER 1 INTRODUCTION DEPRESSION AMONG LATINOS/AS IN THE U.S ACCULTURATION AND ACCULTURATIVE STRESS ACCULTURATIVE STRESS AND DEPRESSION NEIGHBORHOOD CONTEXT AS A PROTECTIVE FACTOR THE CURRENT STUDY...11 CHAPTER 2 METHODS OVERVIEW PARTICIPANTS PROCEDURE MEASURES...16 CHAPTER 3 RESULTS POWER ANALYSIS MISSING DATA...21 vii

9 3.3 DESCRIPTIVE STATISTICS AND CORRELATIONS AMONG STUDY VARIABLES COVARIATES ASSUMPTIONS OF REGRESSION MAIN ANALYSES...24 CHAPTER 4 DISCUSSION ACCULTURATIVE STRESS AND DEPRESSION SYMPTOMS NEIGHBORHOOD CONTEXT AND DEPRESSION SYMPTOMS ACCULTURATIVE STRESS, NEIGHBORHOOD CONTEXT AND DEPRESSION SYMPTOMS LIMITATIONS, STRENGTHS AND IMPLICATIONS...43 REFERENCES...48 viii

10 LIST OF TABLES Table 3.1 Sample Demographic Characteristics...28 Table 3.2 Descriptive statistics, and correlations among study variables and continuous covariates...29 Table 3.3 Results of one-way ANOVA for categorical covariates and study variables...30 Table 3.4 Multiple regression analysis of the relation between acculturative stress and depression symptoms...31 Table 3.5 Multiple regression analysis of the relation between social cohesion and depression symptoms...32 Table 3.6 Multiple regression analysis of the relation between neighborhood safety and depression symptoms...33 Table 3.7 Moderation analysis for acculturative stress, social cohesion, depression symptoms and covariates...34 Table 3.8 Moderation analysis for acculturative stress, neighborhood safety, depression symptoms and covariates Table 3.9 Moderation analysis for acculturative stress, neighborhood safety, social cohesion, depression symptoms and covariates...36 ix

11 CHAPTER 1 INTRODUCTION Latinos/as currently account for 17% of the U.S. population, and it is expected that by 2060 they will make up more than one quarter of the total U.S. population (U.S. Census Bureau, 2015). They are the fastest growing sociodemographic group in the United States. According to data from the U.S. Census Bureau (2015), by 2060 the Hispanic population is expected to increase by 115%. Moreover, there is a record 42.2 million immigrants living in the U.S., making up 13.2% of the nation s population. This represents a fourfold increase since 1960, when only 9.7 million immigrants lived in the U.S., accounting for just 5.4% of the total U.S. population (Pew Research Center, 2016). By force of numbers alone, research that focuses on the needs, strengths and factors contributing to the mental health and well-being of first generation Latinos/as in the U.S. is crucial. Supporting this research need, empirical evidence suggests that Latinos/as in the U.S. report high rates of depression symptoms (Bromberger, Harlow, Avis, Kravitz & Cordal, 2004; Wassertheil-Smoller et al., 2014). Research suggests that depression symptoms among Latinos/as may be associated with factors such as socioeconomic status, education, time of immigration, neighborhood characteristics, acculturation and acculturative stress (Cuellar & Roberts, 1997; Mair, Roux & Galea, 2008; Romero, Ortiz, Finley, Wayne & Lindeman, 2005; Torres, 2010). Although some studies point to 1

12 resilience and protective factors among the Latino/a community, much of the research on Latinos/as focuses on risk factors associated with well-being. For example, studies have pointed out Latino/as are at elevated risk for using alcohol, tobacco, or other drugs on a weekly basis, and reporting depressive mood (Costello, Sewndsen, Rose & Dierker, 2008; Hovey & King, 1996; Perez-Stable, Marín & Marin, 1994; Umaña-Taylor & Updegraff, 2007). Traditionally, minority populations, such as Latinos/as in the U.S., have been subjects of research under a cultural deficit model (Akerlund & Cheung, 2000; Harry & Klingner, 2007; Yosso, 2005). Stemming from the field of education, research under the deficit model tends to highlight the differences of minority groups and states that these groups are different from the majority culture in important ways (Harry & Klingner, 2007). Literature that focuses on risk factors and deficits can be stigmatizing and contribute to negative stereotypes (Dixon & Rosenbaum, 2004). Additionally, the cultural deficit model overlooks the strengths of Latinos/as. Focusing solely on risk factors may represent a missed opportunity to incorporate important information into the conceptualization of factors associated with depression among Latinos/as. One factor that may influence depression symptoms is neighborhood context. There is evidence to suggest that neighborhood factors, such as social cohesion and neighborhood safety may buffer the relation between acculturative stress and depression (Kim, 2008). Questions remain regarding the experiences and issues faced by Latinas/os as they encounter American culture, especially first generation immigrants. Moreover, more evidence is needed around factors that might be protective of Latino/a well-being and that highlights their strengths. Thus, we conducted a study that explores the relations among 2

13 acculturative stress, neighborhood context and depression among Latino/a adults. Specifically, examined neighborhood context as a moderator between acculturative stress and depression. 1.1 Depression among Latinos/as in the U.S. Given that rates of depression contribute to the global burden of disease and that it affects people of all communities across the world, the World Health Organization has categorized depression as a global public health concern (Marcus, Yasamy, Ommeren, Chisholm & Saxena, 2012). Depression is a serious disorder that affects individuals of all backgrounds. Symptoms of depression include anhedonia (i.e., loss of pleasure), sadness, irritability, sleep disturbances, and difficulty engaging in ordinary tasks, among others (American Psychiatric Association, 2013). It is reported that one in ten people in the U.S. experiences depression. Moreover, over 80% of people that have symptoms of clinical depression are not receiving any specific treatment. The rate of individuals diagnosed with depression increases by 20% every year (Pratt & Brody, 2014). It has been documented that Latinos/as in the U.S. report high rates of depression (Alegría, Mulvaney-Day, Torres, Polo, Cao & Canino, 2007). The Hispanic Community Health Study/Study of Latinos is the most thorough study of Latinos/Hispanics to date. It consists of a probability sample of 161,415 Latino/a persons aged 18 to 74 (Wasserheil- Smoller et al., 2014). These authors found that prevalence of depression among Latinos/as is 27% compared to 7.6% in the overall population (Pratt & Brody, 2014; Wassertheil-Smoller et al., 2014). This rate is influenced by several factors like gender and country of origin. For example, it was lowest among participants of Mexican origin (22.3%) and highest among Puerto Ricans (38%), even after controlling for demographic, 3

14 lifestyle and comorbid conditions. Similar to rates in the general population, women were more likely than men to report high symptoms of depression (32.8% vs. 20.7%) (Wassertheil-Smoller et al., 2014). These findings are in line with the Study of Women s Health Across the Nation (SWAN) that looked at the prevalence of depression among women in the U.S. (Bromberger et al., 2004). The Study of Women s Health Across the Nation evaluated 3302 women aged 42 to 52 from multiple ethnic backgrounds and locations across the U.S. Findings revealed that Hispanic women had the highest odds of reporting high scores of depressive symptomatology, even after controlling for socioeconomic status, level of education, and age. Additionally, Liang, Xu, Quiñones, Bennet and Ye (2011) found that Hispanics have different trajectories across time when it comes to depressive symptoms. In their study, Liang et al. (2011) identified six major trajectories for depression: (1) minimal depressive symptoms, (2) low depressive symptoms, (3) moderate and stable depressive symptoms, (4) high but decreasing depressive symptoms, (5) moderate but increasing depressive symptoms, and (6) persistently high depressive symptoms. Overall, they found that Hispanics were more likely to belong in trajectories with elevated depressive symptoms when compared to non-latino whites (Liang et al., 2011). In brief, Latino/as report high rates of depression and there is evidence to suggest significant disparities when comparing this population to other groups. Some studies suggest that Latinos/as are less than half as likely as whites to receive treatment for depression (Lagomasino, Dwight-Johnson, Miranda, Zhang, Liao, Duan & Wells, 2005). Thus, it is critical to explore the factors associated with depression among these 4

15 individuals to inform treatment and intervention. Scholars suggest that acculturative stress is an important contributing factor for depression among Latinos/as. 1.2 Acculturation and Acculturative Stress Acculturation is often associated with the study of the Latino/a population. Acculturation was originally conceptualized by Gordon (1964) as a unidimensional process in which retention of the heritage culture and acquisition of the receiving culture were cast as opposing ends of a single continuum (Schwartz et al., 2010, p. 239). The study of acculturation has greatly evolved and can now be understood as the process of adapting and navigating cultures as an individual encounters a new society (Organista, Organista & Kurasaki, 2003). Acculturation has also been associated with acculturative stress (Torres, 2010; Torres, Driscoll & Voell, 2012). Some authors suggest that acculturative stress is the pressure to adapt to the majority culture that is not one s own, or the stress that comes from the process of acculturation (Berry, 1997). However, these early explanations don t account for some of the nuances that occur within the phenomenon of acculturative stress. Moreover, they only focused on the acquisition of behaviors and cognitions from the host culture and not maintaining practices from one s heritage culture (Rodriguez, Myers, Mira, Flores & Garcia-Hernandez, 2002; Sarmiento & Cardemil, 2009). Given the limitations of previous conceptualizations, several authors have more recently proposed that acculturative stress stems from pressures individuals may face when navigating two cultures (Driscoll & Torres, 2013; Rodriguez, Flores, Flores, Myers, & Vriesema, 2015; Rodriguez et al., 2002). As Latinos/as encounter U.S. culture, they may face different challenges, such as acquiring a new language, navigating a different 5

16 system, and building sources of support (Rodriguez et al., 2015). These events shape a way of living for Latinos/as. In daily interactions, Latinos/as may feel pressured to adapt. This pressure to adapt can be shown in demands to learn English, adapt to the American way of doing things, or difficulty fitting in with the majority group. On the other hand, Latinos/as may also face demands from their heritage culture to maintain certain behaviors, like speaking Spanish or practicing Hispanic/Latino customs (Driscoll & Torres, 2013; Rodriguez et al., 2002). The study of acculturative stress has revealed evidence to suggest its relation to depression and many other mental health outcomes; for the purposes of this study we focused only on depression. 1.3 Acculturative Stress and Depression There is a strong body of literature that associates acculturative stress with depression (D Anna-Hernandez, Aleman & Flores, 2015; Driscoll & Torres 2013; Sarmiento & Cardemil, 2009; Torres, 2010; Torres, Driscoll & Voell, 2012; Zeiders, Umaña-Taylor, Updegraff & Jahromi, 2015). Among pregnant Mexican women, depressive symptoms have been associated with acculturative stress; specifically, women who experienced greater acculturative stress reported significantly elevated depressive symptoms during pregnancy (D Anna-Hernandez, Aleman & Flores, 2015). Moreover, authors have found that adherence to Mexican values, such as familism, respect, religion, and traditional gender roles, protected against the negative effects of acculturative stress on maternal depression. The opposite was true for mainstream or American values such as material success, independence, self-reliance, competition and personal achievement (D Anna-Hernandez, Aleman & Flores, 2015). 6

17 Driscoll and Torres (2013) also found a relation between acculturative stress and depression among Midwestern Latino/a adults. The authors utilized a stress and coping framework in which active coping is defined as applying one s own resources to deal with a stressful situation (Zeidner & Endler, 1996). Driscoll and Torres (2013) found that active coping partially mediates the relation between acculturative stress and depression. Their findings suggest that lowered active coping significantly contributes to the relation between acculturative stress and depression among Latino/as (Driscoll & Torres, 2013). Few studies have explored the association between acculturative stress and depression among Latino/a families. Sarmiento and Cardemil (2009) studied Latino/a heterosexual couples living in Massachusetts. Their sample consisted of 80 firstgeneration immigrants from 11 different Latin American countries. The authors found that, among women, acculturative stress and poor family functioning (e.g., difficulties making decisions as a family, few displays of affection, unclear family boundaries) contribute to higher depression symptoms. These findings suggest that family dynamics contribute to Latino/a well-being. However, the authors acknowledge that there may have been instrumental or external factors (e.g., language barriers, lack of insurance, lack of services) that contributed to these findings (Sarmiento & Cardemil, 2009). Taken together, these findings suggest that there is a relation between depression and acculturative stress for Latino/as of different backgrounds (D Anna-Hernandez, Aleman & Flores, 2015; Driscoll & Torres, 2013). Most studies have been carried out with youth, but few with adults (Sarmiento & Cardemil, 2009; Zeiders, Umaña-Taylor, Updegraff & Jahromi, 2015). Additionally, the factors that contribute to this relation are still unclear, and external factors such as neighborhood context remain unexplored. 7

18 Specifically, studies often fail to include factors that may explain the relation between acculturative stress and depression. Evidence suggests that one important factor to consider is neighborhood context. 1.4 Neighborhood Context as a Protective Factor Authors suggest that if we wish to understand why some groups are healthier than others, we must consider social factors for explanations (Kawachi & Berkman, 2003). Research in the ecological tradition that shifts away from focusing on individual characteristics suggests that there may be a link between health issues, such as depression, and external factors, such as neighborhoods (Duncan, Duncan, Okut, Strycker, Hix-Small, 2003; Haines, Beggs, Hurlbert, 2011; Mair, Diez-Roux & Galea, 2015). There are numerous ways of defining a neighborhood. One way can be characterized by physical markers, such as a group of blocks or buildings, a group of houses guarded by a gate, or sign or the name of a street. Morenoff, Sampson and Raudenbush (2001) reflect on how the modern notion of a neighborhood goes well beyond physical borders or markers. Networks are likely to surpass traditional physical markers and thus social interactions may not always be neatly contained within said boundaries (Ansari, 2013). Two features of the neighborhood context, namely neighborhood social cohesion and neighborhood safety, have recently gained attention in the literature. The sociology field has studied social cohesion within neighborhoods as a key factor to understand how neighborhoods affect mental and physical health (Rios, Aiken & Zautra, 2012). Social cohesion refers to the degree of connectedness and trust among neighbors; some authors have also used the term sense of community to conceptualize 8

19 social cohesion (Alegria et al., 2007; Kawachi & Berkman, 2014; Kim et al., 2013). Social cohesion also refers to social bonds among people that contribute to continuous participation and group formation (Rios, Aiken & Zautra, 2012). Social cohesion is closely related to social capital, which refers to features of social structures (e.g., levels of interpersonal trust and norms of reciprocity and mutual aid) which act as resources for individuals and facilitate collective action (Kawachi & Berkman, 2014). While economic capital may be in people s bank accounts or properties, social capital resides in social networks that allow people to build relationships. Social capital also works as a form of social control (Ansari, 2013; Sampson, Raudenbush & Earls, 1997; Sampson, 2003). Broadly, social control allows the members of a community to accomplish shared goals and to regulate behavior according to desired and established communal norms to ensure the general well-being of its members (Ansari, 2013). Evidence suggests that neighborhoods characterized by trust, mutual aid, and support among residents might promote pathways for positive health outcomes (Cattell, 2001; Echeverría et al., 2008; Gee and Payne-Sturges, 2004; Hong, Zhang & Walton, 2014; Kawachi and Berkman, 2000; Mulvaney-Day, Alegria & Sribney, 2007; O Campo, Salmon & Burke, 2009). Some studies suggest that social cohesion may provide emotional support and a climate that encourages enhanced mental health via positive psychosocial processes (Kawachi & Berkman, 2000). Social cohesion may also promote healthy norms of living, such as encourage physical activity, and a healthy diet (Hong et al, 2014; Kawachi & Berkman, 2000). The theoretical importance of social cohesion is supported by an emerging literature that empirically examines its relation to various 9

20 mental health outcomes, including anxiety, depression, general mental health status, and self-rated mental health (Cutrona et al., 2000; Mair et al., 2010; McCulloch, 2001; Mulvaney-Day et al., 2007). Assessing neighborhood safety is also important in the study of neighborhood context. Kaplan and Kaplan (2003) suggest that individuals who don t perceive their neighborhoods as safe may be less likely to engage with their neighbors and utilize physical resources available to them (e.g., parks, sidewalks). For example, the Broken Windows Theory postulates that small indicators of public disorder (e.g., graffiti, gang presence) may lead to negative health outcomes and overall urban decay. If a window is broken in a neighborhood house, and it isn t promptly fixed, this may be a symptom of disorganization, lack of resources, and poor social cohesion. This theory also suggests that one marker of disorder will lead to others (Sampson & Raudenbush, 2004). Research also suggests that neighborhood problems may be a source of chronic stress that can contribute to poor mental health outcomes (Kim, 2008). Similarly, a poor perception of neighborhood safety may limit the extent to which individuals can be physically active in their area of residence, and thus decrease physical activity levels necessary to maintain health (Macera, 2003). For example, authors suggest that individuals who fear being robbed, attacked, or physically injured are less likely to report walking for pleasure, exercise, or transportation (Ross, 2000). However, little is known about how these neighborhood-level variables operate for Latinos. This is also particularly complex given the broad experiences of community influences for this diverse group. For example, for recent immigrants, help-seeking and health care patterns may be primarily influenced by experiences in their country of origin 10

21 and not their current social context (Alegria et al., 2007; Portes, Kyle, & Eaton, 1992). Moreover, little is known about how neighborhood context influences health outcomes in latter generations. The current study addresses these gaps in the literature by exploring how neighborhood context, specifically social cohesion and neighborhood safety, may influence the wellbeing of Latino/a immigrants. 1.5 The Current Study As the Latino/a population grows in the U.S. (U.S. Census Bureau, 2015), they may experience acculturative stress which may in turn be a predictor for depression symptoms (Driscoll & Torres, 2013; Torres, 2010). A factor that may be associated with this relation is neighborhood context; there is evidence to suggest that neighborhood context may be a buffer between acculturative stress and depression. However, little is known about neighborhood context as a protective factor for depression among first generation Latino/as. Given that acculturative stress is strongly associated with depression among the Latino/a population, the current study aimed to confirm whether the association between acculturative stress and depression that has been reflected in the literature holds for this sample. We also explored the relations among neighborhood social cohesion, neighborhood safety, and depression. Moreover, this study explored whether neighborhood social cohesion, and neighborhood safety act as a buffer between acculturative stress and depression among first generation Latinos/as. Findings from the present study are expected to contribute to the literature on depression among first generation Latino/as. Results could also elucidate some factors that might protect Latino/as from higher levels of depression, like neighborhood social cohesion and 11

22 neighborhood safety. Understanding these factors might inform systematic forms of intervention, such as working with Latino/a communities to promote cohesiveness and social support. Specific research questions and hypotheses for this study are as follows: Research Question 1a: Is acculturative stress associated with depression among first generation Latino/a adults in the U.S.? Hypothesis 1a: Higher levels of acculturative stress will be related to higher levels of depression among first generation Latino/a adults in the U.S. Research Question 1b: Is social cohesion associated with depression among first generation Latino/a adults in the U.S.? Hypothesis 1b: Higher levels of social cohesion will be related to lower levels of depression among first generation Latino/a adults in the U.S. Research Question 1c: Is neighborhood safety associated with depression among first generation Latino/a adults in the U.S.? Hypothesis 1c: Higher levels of neighborhood safety will be related to lower levels of depression among first generation Latino/a adults in the U.S. Research Question 2a: Does neighborhood social cohesion moderate the relation between acculturative stress and depression among first generation Latino/a adults in the U.S.? Hypothesis 2a: Higher levels of social cohesion will buffer the impacts of acculturative stress on depression among first generation Latino/a adults in the U.S. Research Question 2b: Does neighborhood safety moderate the relation between acculturative stress and depression among first generation Latino/a adults in the U.S.? 12

23 Hypothesis 2b: Higher levels of neighborhood safety will buffer the impacts of acculturative stress on depression. Exploratory Question 3: Do neighborhood social cohesion and neighborhood safety interact to moderate the relation between acculturative stress and depression among first generation Latino/a adults in the U.S.? Hypothesis 3: An interaction between higher levels of neighborhood safety and higher levels of social cohesion will buffer the impacts of acculturative stress on depression. 13

24 CHAPTER 2 METHODS 2.1 Overview Analyses were conducted using data from the National Latino Asian American Study (NLAAS). Data is publicly available through the Inter-University Consortium for Political and Social Research (ICPSR). The NLAAS sought to better understand the intra and inter group ethnic and racial differences linked to psychiatric disorders and service use. The NLAAS collected cross-sectional data from both Latino and Asian American populations. For the current study, we conducted analysis using only the data collected from Latino/a respondents. Data collection took place between May 2002 and December The NLAAS utilized a sample of Latinos/as 18 years and older residing in the United States (Alegría et al., 2007). Latino/a participants consisted of 2,554 respondents; first generation participants consisted of 1,630 respondents. A stratified probability design was implemented to attain a nationally representative sample of Latino/as. The weighted sample was similar in terms of gender, age, educational level, marital status, and geographic distribution to the 2000 U.S. census. However, the NLAAS sample included more U.S. immigrants and more individuals with low income; this was in part due to increased access to undocumented Latino/a populations (Alegría et al., 2007). Detailed information on the NLAAS protocol for data collection has been documented by Alegría et al. (2004) and Heeringa et al. (2004) 14

25 2.2 Participants We utilized data from 1,630 first generation immigrants not born in the U.S. mainland. Participants in the current study were 724 females and 906 males (55.6%); mean age was 43 years old (SD=15.83). In terms of ancestry/racial identification, 217 were Puerto Rican, 501 Cuban, 488 Mexican, and 424 were classified in the Other Hispanic/Latino subcategory. Respondents in the Other Hispanic/Latino subcategory include participants whose ancestry or origin was from Colombia, the Dominican Republic, El Salvador, Ecuador, Guatemala, Honduras, Peru, and Nicaragua. Median annual household income was $27,000 (M=$40,647; SD=43,244). More information about participants demographic characteristics can be found in Table Procedure The sample frame or sample universe for the NLAAS were Latino/a American, Asian American, and non-latino/a, non-asian White American adults aged 18 and older residing in households located in the United States and the state of Hawaii. A 4-stage probability sample design was implemented, which included: (1) U.S. metropolitan statistical areas and counties; these are areas with high population density, (2) area segments; these are census blocks or combinations of census blocks with a minimum number of households, (3) housing units, selected by field staff, in area segments, and (4) screening interview to classify persons by domain (Heeringa et al., 2004). The overall response rate was 75.5%. The sample is distributed with 25.6% participants from the Northeast region, 6.4% from the Midwest region, 40.8% from the South region, and 27.2% from the West region. Potential participants were first provided with a brochure and letter of 15

26 introduction in Spanish and English. Following consent procedures, trained professionals screened and interviewed participants about mental health and mental health-related matters (Lueck et al., 2011; Heeringa et al., 2004). Interviewers were of similar cultural and linguistic backgrounds as participants. During the data collection phase, respondents were asked whether they spoke English, some English, or no English. Participants who spoke some English or no English were interviewed in Spanish. Individuals who were fluent in English and Spanish, thus considered bilingual, were randomly interviewed in either language (Alegría et al., 2007). All measures were administered via face-to-face interviews carried out with computer-assisted software. Each interview lasted an average of 2.4 hours. Written consent was obtained from all participants in their language of choice. All recruitment, consent and interview procedures were approved by the Institutional Review Boards of the Cambridge Health Alliance, the University of Washington, and the University of Michigan. Data was later analyzed utilizing SPSS, Version 24 (IBM Corp., 2013). 2.4 Measures Measure adaptation. The NLAAS instruments were available in English and Spanish. All measures were translated from English into Spanish with standard translation and back-translation techniques. This was accomplished by translating the measures from English to Spanish, then having them translated back into English to check for equivalency in the domains of content, semantic structure, criterion and conceptual equivalence, and technical equivalence. Translation procedures included the use of cultural idioms in Spanish that applied to the different ethnic groups under study. This included using words that were understood by different Latino/a subgroups under 16

27 study. Interviewers used a list of equivalent words as a tool to adapt certain language nuances to each subgroup. This procedure ensured that the same theoretical concept was being measured across groups (Alegría et al., 2009; Lueck & Wilson, 2011) Acculturative Stress. Acculturative Stress was assessed using a 10-item scale that measures cultural change as a result of immigrating to the United States (Gee et al., 2007; Cervantes et al., 1990). The measure was adapted from the Mexican American Prevalence and Services Survey (Vega et al., 1998) and the Hispanic Stress Inventory (Cervantes et al., 1990). Items include Do you feel guilty for leaving family or friends in your country of origin? ; Do you avoid seeking health services due to fear of immigration officials?. This scale has been mainly used to operationalize acculturative stress with Mexican American populations (Alegria et al., 2004; Finch, Hummer, Kolody & Vega, 2001). The scale had dichotomous response categories of yes (1) or no (5). Previous studies have found Cronbach s alphas of 0.61 when the scale was administered in English, and of 0.70 when the scale was administered in Spanish (Alegria et al., 2004). High scores in this scale depict higher levels of acculturative stress, while low scores imply the opposite. The internal consistency reliability coefficient for the current study was α = Neighborhood Context. Neighborhood Context was measured using the Social Cohesion Scale and the Neighborhood Safety Scale. The Social Cohesion scale is a 4-item scale and asks whether people in the neighborhood can be trusted and get along with each other (Sampson, Raudenbush & Earls, 1997). The 4 response categories ranged from very true (1) to not at all true (4). Minimum and maximum scores are 4 and 16 respectively. Items included People in this neighborhood can be trusted, People in this 17

28 neighborhood generally get along with each other, I have neighbors who would help me if I had an emergency, and People in my neighborhood look out for each other. Simple additive scores were calculated for this measure. In the original scale, higher scores indicated a lesser degree of social cohesion than lower scores. For clarity and ease of interpretation, we reversed scores to reflect higher scores to higher levels of social cohesion. Previous studies have found Cronbach s alphas of 0.81, both when the scale was administered in English, and in Spanish (Alegria et al., 2004). The internal consistency reliability coefficient for the current study is α = The Neighborhood Safety scale is a 3-item measure that evaluates the respondent's perceived level of neighborhood safety and neighborhood violence (Alegria et al., 2004). Response categories also ranged from very true (1) to not at all true (4). Items were modified from the National Longitudinal Study of Adolescent Health (Resnick et al., 1997). Items included I feel safe being out alone in my neighborhood during the night, People often get mugged, robbed or attacked in my neighborhood, and People sell or use drugs in my neighborhood. The latter two items were reverse scored. High scores in this scale depict higher levels of neighborhood safety, while low scores imply the opposite. Previous studies have found Cronbach s alphas of 0.75 when the scale was administered in English, and of 0.70 when the scale was administered in Spanish (Alegria et al., 2004). Simple additive scores were calculated for this measure. The internal consistency reliability coefficient for the current study is α = Depression. Depression was measured using the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). The CIDI was designed to be used by trained interviewers who are not clinicians (Kessler, Andrews, Mroczek, 18

29 Ustun, Hans-Ulrich, 1998). The CIDI can generate diagnoses according to definitions from eight DSM-IV syndromes (American Psychiatric Association, 1994). These include: major depressive episodes (MD), generalized anxiety disorder (GAD), simple phobia (SiP), social phobia (SoP), agoraphobia with or without panic (AG), panic attacks (PA), alcohol dependence (AD), and drug dependence (DD) (American Psychiatric Association, 1994). Studies suggest that there may be cultural differences in the diagnosis and classification of depression; however, it has also been suggested that cultural equivalence was reached on this measure (Nicklet & Burgard, 2009). Section A (questions A1 through A9) of the CIDI measure for Major Depression (MD) is designed to classify respondents according to the criteria of a DSM-IV major depressive episode (American Psychiatric Association, 1994). This section consists of six main questions, and 14 secondary questions. There are two ways to meet the diagnostic stem requirement for MD: either to endorse all questions about having two weeks of dysphoric mood or to endorse all questions about having two weeks of anhedonia. Each series requires the respondent to report two weeks of this symptom lasting at least most of the day, at least almost every day. Either denying the existence of the symptom or denying persistence leads to a skip-out and the respondent receives a probability of caseness equal to zero. If the respondent endorses either the dysphoric or the anhedonia stem series, an additional fourteen symptom questions are asked regarding: losing interest, feeling tired, change in weight, trouble with sleep, trouble concentrating, feeling down, psychomotor agitation or retardation, feelings of worthlessness, and thoughts about death. The respondent's depression symptom count is then calculated as the sum of positive responses to each of these fourteen symptom questions. Some symptoms include 19

30 two questions regarding changes in behavior, these are counted as one point in the final symptom count which ranges from 0 to 9 (American Psychiatric Association, 1994; Nelson, Kessler & Mroczek, 2002); we used this symptom count as a continuous variable for depression symptoms. Higher scores indicate higher probability of an individual being diagnosed with MD. The validity of the CIDI diagnostic assessment in the current study was consistent with those obtained independently in other studies by trained clinical interviewers (Wittchen, 1994). Internal consistency reliability coefficient analyses were not appropriate to carry out given that this is considered a symptom count. Moreover, previous studies that compare the CIDI MDD subscale to the Center for Epidemiologic Studies Depression Scale (CESD), suggest that the CIDI may be a more sensitive measure when determining a Major Depression Disorder diagnosis than the CESD. The CESD may be a broader, more heterogeneous measure of negative mood or emotional distress than a measure of depressive affect alone (Fisher et al, 2007). 20

31 CHAPTER 3 RESULTS 3.1 Power Analysis Post-hoc power analysis was conducted to determine whether analyses were adequately powered to identify the effects of interest. The power analysis was conducted with the software G*Power (release ; Faul, Erdfelder, Lang, & Buchner, 2009). These analyses were conducted in relation to the interaction term associated with the multiple linear regression of research question 3A. This was used as an estimate of the lower bound of power requirements given that this model required the most power to detect an effect. Given a sample size of 1,630 participants, alpha of 0.05, and assuming d=0.8, adequate power was achieved to detect large effect sizes. Power to detect a large effect size was also adequate for analyses carried out with a subset of the sample that consisted of 349 participants. 3.2 Missing Data Less than 20% of the final sample contained missing data. Some cases were deleted due to missing data; the number of such cases was six. We utilized standard listwise deletion in cases with missing data. The PROCESS for SPSS macro automatically performs listwise deletion when missing values are found (Hayes, 2013). These procedures for handling missing data are consistent with current best practices and have been shown to decrease the potential impact of bias on results (Enders, 2010; Graham, 2009; Schafer & Graham, 2002). 21

32 3.3 Descriptive Statistics and Correlations Among Study Variables Frequencies and distributions for all categorical demographic characteristics are presented in Table 3.1. Demographic characteristics, means and standard deviations for all continuous demographic variables are presented in Table 3.2. Mean scores for acculturative stress were 2.58 (SD=1.78); scores ranged from 0 to 9. Scores for neighborhood social cohesion ranged from 1 to 16; mean score for this scale was (SD=3.17). Neighborhood safety scores ranged from 1 to 12, mean score for this scale was 8.99 (SD=2.74). Finally, 21.5% of respondents reported at least one depression symptom; the overall depression symptom count showed an average of 1.41 (SD=2.84, range: 0-9). There were several predictor variables that were significantly correlated with the outcome variable as well as the moderator variables (see Table 3.2). As expected, acculturative stress was positively correlated with depression symptoms; as acculturative stress increased so did depression symptoms (r=.09; p<.05). Another correlation that provided expected outcomes was the negative correlation between acculturative stress and neighborhood social cohesion (r=-.13; p<.05); that is, as acculturative stress increased, social cohesion decreased. Acculturative stress was also negatively associated with neighborhood safety (r=-.14; p<.05), which means that as acculturative stress increased, perception of neighborhood safety decreased; this was also the expected result for this analysis. Neighborhood safety was negatively correlated with depression symptoms (r=-.11; p<.05); in this case, as neighborhood safety decreased, depression symptoms increased. This was also an expected outcome. One finding that was not expected was the non-significant correlation among neighborhood social cohesion and 22

33 depression symptoms (r=-.20; p>.05); we expected that lower neighborhood social cohesion would be related to higher levels of depression symptoms. Finally, moderator variables neighborhood social cohesion and neighborhood safety were positively correlated (r=.47; p<.05); as social cohesion increased so did neighborhood safety. We expected this finding. 3.4 Covariates Pearson correlations were conducted to explore the relation between the continuous variables age and household income and all study variables. Significant correlations were found among all study variables, age, and household income. One-way ANOVA was also conducted to explore the effects of the categorical variables of age at immigration, sex, citizenship status, and race/ancestry on study variables and determine whether these should be used as covariates. Results yielded from these analyses led us to utilize age, household income, sex, race/ancestry, and citizen status as control variables. Results from these analyses can be found in Tables 3.2 and Assumptions of Regression The assumptions of multiple regression linearity, homoscedasticity and multicollinearity were assessed. Partial regression plots showed an approximately linear relation between the continuous predictor variables and the outcome variable. Homoscedasticity of residuals was indicated for all variables, as assessed by equally spread residuals across the scatter plots of studentized residuals and (unstandardized) predicted values. Examination of bivariate correlations were examined and Tolerance/VIF values indicated absence of multicollinearity in all variables. Moreover, absence of significant outliers was examined by inspecting each case s standardized 23

34 residual as well as the studentized deleted residual. Cases that were greater than +/-3 standard deviations were considered outliers and were deleted from the dataset. Outliers that were removed included three cases of the neighborhood social cohesion variable and four cases from the acculturative stress variable; we only removed cases within each variable. Finally, examination of histograms, P-P Plots, Q-Q Plots, as well as skewness and kurtosis values indicated normal distribution of errors (residuals) for all variables except for the depression symptoms outcome variable. Given that skewness in this variable is consistent with depression rates among the overall population, we carried out analyses without transforming the data. To assess possible biases in result interpretation, we also carried out analyses with a subset of the data that consisted of 349 participants that reported at least one depression symptom. 3.6 Main Analyses We present results guided by research questions 1 through 3. Regression analyses were conducted to address research question 1a (Is acculturative stress associated with depression among first generation Latino/a adults in the U.S.?), 1b (Is social cohesion associated with depression among first generation Latino/a adults in the U.S.?) and 1c (Is neighborhood safety associated with depression among first generation Latino/a adults in the U.S.?). Moderation analyses were conducted to address research questions 2a, 2b and 3. A moderation analysis was conducted to examine research question 2a (Does neighborhood social cohesion moderate the relation between acculturative stress and depression?). A second moderation analysis was to examine research question 2b (Does neighborhood safety moderate the relation between acculturative stress and depression?). 24

35 To examine exploratory research question 3 (Do neighborhood safety and neighborhood social cohesion interact to moderate the relation between acculturative stress and depression?), we carried out a moderated moderation analysis. We utilized the PROCESS macro for SPSS (Hayes, 2013) to carry out all moderation analyses Acculturative stress and depression symptoms. Results yielded from regression analyses utilizing the full sample (N=1,624) indicated that acculturative stress significantly predicted depression symptoms (β=.20, p<.001). The results of the regression indicated that acculturative stress explained 5% of the variance while controlling for race/ancestry, age, gender, citizen status, and household income (R 2 =0.05, F(6,1613)=13.55). Results yielded from regression analyses utilizing a subset of the sample reporting at least one depression symptom (N=349) indicated that acculturative stress did not predict depression symptoms (β=.07, R 2 =0.06, F(6,341)=3.37, p>.05); see Table Social cohesion and depression symptoms. Results yielded from regression analyses utilizing the full sample (N=1,624) indicated that social cohesion did not predict depression symptoms (β=-.03, R 2 =0.04, F(6,1595)=10.3, p>.05). Results yielded from regression analyses utilizing a subset of the sample reporting at least one depression symptom (N=349) also indicated that social cohesion did not predict depression symptoms (β=-.02, R 2 =0.05, F(6,339)=3.16, p>.05); see Table Neighborhood safety and depression symptoms. Results yielded from regression analyses utilizing the full sample (N=1,624) indicated that neighborhood safety significantly predicted depression symptoms (β=-.11, p<.001). Neighborhood Safety explained 5% of the variance while controlling for race/ancestry, age, gender, 25

36 citizen status, and household income (R 2 =0.05, F(6, 1608)=13.6). Results yielded from regression analyses utilizing a subset of the sample reporting at least one depression symptom (N=349) indicated that neighborhood safety did not predict depression symptoms (β=-.04, R 2 =0.06, F(6, 338)=3.28, p>.05); see Table Acculturative stress, social cohesion and depression symptoms. Simple moderation analyses were conducted to determine whether social cohesion moderated the relation between acculturative stress and depression symptoms. Results yielded from these analyses indicated that this interaction term was nonsignificant for the full sample (β=.01, R 2 =0.05, F(8, 1589)=10.6, p>.05). Results yielded from moderation analyses utilizing a subset of the sample reporting at least one depression symptom (N=349) indicated that social cohesion didn t moderate the relation between acculturative stress and depression symptoms (β=-.003, R 2 =0.05, F(8, 337)=2.53, p>.05); see Table Acculturative stress, neighborhood safety and depression symptoms. Simple moderation analyses were conducted to determine whether neighborhood safety moderated the relation between acculturative stress and depression symptoms. Results yielded from these analyses indicated that this interaction term was nonsignificant for the full sample (β=-.01, R 2 =0.05, F(8, 1596)=12.5, p>.05). Results yielded from moderation analyses utilizing a subset of the sample reporting at least one depression symptom (N=349) indicated that neighborhood safety didn t moderate the relation between acculturative stress and depression symptoms (β=-.011, R 2 =0.06, F(8, 336)=2.65, p>.05); see Table Acculturative stress, social cohesion, neighborhood safety, and depression symptoms. Moderated moderation analysis was conducted to determine 26